MetaTOC stay on top of your field, easily

This study reviews the economic viability of the Rashtriya Swasthya Bima Yojana (RSBY), India's landmark health insurance program for below poverty line (BPL) populations in West Bengal state of India. It addresses the issue through in‐depth analysis of literature, national and state level data, and a number of key stakeholder interviews. The study argues that the market failure conditions of this insurance model will continue to perpetuate losses for not only the state, but also for insurance companies, unless they adjust on a continuous basis for profit by raising the premium rate. This will further deplete state budgets for health care affecting the viability of the scheme in the long run.

Objective To quantify the effect of Medicaid expansions on office‐based care among the newly eligible. Data Source 2008–2014 Medical Expenditure Panel Survey. Study Design The main sample is adults age 26–64 with incomes ≤138% of poverty who were not eligible for Medicaid prior to the Affordable Care Act. For this population, difference‐in‐differences linear probability models compare utilization between expansion and nonexpansion states and between 2008–2013 and 2014. Extraction Methods Medicaid eligibility is simulated using data on family relationships, state of residence, and income. Principal Findings Relative to comparable adults in nonexpansion states, newly eligible adults in expansion states were 9.1 percentage points more likely to have any office‐based primary care physician visit in 2014, a 21.4% increase from 2013 (p‐value = .004); 6.9 percentage points more likely to have a specialist visit, a 25.2% increase from 2013 (p‐value = .036); and 5.1 percentage points more likely to have a visit with a nurse practitioner, nurse, or physician assistant, a 34.5% increase from 2013 (p‐value = .016). Conclusions State Medicaid expansions in 2014 were associated with greater likelihoods of visits with a variety of office‐based providers. The estimated effects are larger among newly eligible compared with previous estimates on broader populations of low‐income adults.

Objective To explore organizations’ experiences providing family planning during the first year of an expanded primary care program in Texas. Data Sources Between November 2014 and February 2015, in‐depth interviews were conducted with program administrators at 30 organizations: 7 women's health organizations, 13 established primary care contractors (e.g., community health centers, public health departments), and 10 new primary care contractors. Study Design Interviews addressed organizational capacities to expand family planning and integrate services with primary care. Data Extraction Interview transcripts were analyzed using a theme‐based approach. Themes were compared across the three types of organizations. Principal Findings Established and new primary care contractors identified several challenges expanding family planning services, which were uncommon among women's health organizations. Clinicians often lacked training to provide intrauterine devices and contraceptive implants. Organizations often recruited existing clients into family planning services, rather than expanding their patient base, and new contractors found family planning difficult to integrate because of clients’ other health needs. Primary care contractors frequently described contraceptive provision protocols that were not evidence‐based. Conclusions Many primary care organizations in Texas initially lacked the capacity to provide evidence‐based family planning services that women's health organizations already provided.

Aim To cross‐culturally adapt and validate the Comprehensive Frailty Assessment Instrument (CFAI) among Chinese community‐dwelling older adults. Methods The Chinese CFAI was developed through forward–backward translations. An urban sample of 1235 community‐dwelling older adults received face‐to‐face interviews to examine the validity (construct validity and criterion validity) and reliability (internal consistency and test–retest reliability). Results The Chinese CFAI achieved semantic and idiomatic equivalence, and showed acceptable reliability and an expected factor structure, except for the social support domain. The exploratory factor analysis extracted five factors explaining 53.8% of the total variance of frailty. The confirmatory factor analysis showed that the data fit well to the second‐order factor theoretical model, with a root mean square error of approximation of 0.05, Tucker‐Lewis Index of 0.93 and Comparative Fit Index of 0.95. The receiver operating characteristic analysis presented an acceptable criterion validity using the Rockwood Frailty Index as an external criterion (area under the curve 0.80), with balanced sensitivity (65.31%) and specificity (81.19%) at the optimal 39‐point frailty cut‐off of the CFAI. Conclusions The Chinese CFAI has good validity and reliability as a practical frailty measure in Chinese community‐dwelling older adults.

Aim The aim of the present study was to investigate the relationship between physical activity (PA) and depressive symptoms in community‐dwelling older Japanese adults. Methods A cross‐sectional study design was used to obtain data from 3191 community‐dwelling older Japanese adults aged 70–95 years. Depressive symptoms were assessed using self‐reported scores on the Geriatric Depression Scale‐15. PA was objectively measured using an accelerometer worn for a maximum of 40 days, and average daily durations of light‐intensity PA (LPA), moderate‐to‐vigorous intensity PA (MVPA) and step count were calculated. PA was compared between participants with and without depressive symptoms by carrying out analysis of covariance and multivariable logistic regression analysis adjusted for all covariates by using propensity scores. Results Depressive symptoms were present in 598 participants (19.6%). A comparison of propensity‐score adjusted PA showed that step count (5059.6 ± 53.7 vs 5003.0 ± 112.1 count/day; P = 0.652) and moderate‐to‐vigorous intensity PA duration (23.0 ± 0.4 vs 23.8 ± 0.7 min/day; P = 0.358) were not significantly different between participants with and without depressive symptoms, respectively. However, participants without depressive symptoms had a significantly higher LPA duration than those with depressive symptoms (39.4 ± 0.3 vs 37.3 ± 0.7 min/day, respectively; P < 0.01). Conclusions The present results suggest that individuals with lower LPA have a higher risk of depressive symptoms. These findings imply that PA recommendations, especially for older adults, should emphasize LPA, which appears to be especially effective at preventing depressive symptoms.

Aim To evaluate the relationship between kidney function without diabetes and components of the frailty phenotype in community‐dwelling Japanese older adults. Methods Participants were 8343 residents who completed baseline assessments, classified into four categories according to eGFR. Frailty status was defined using five criteria: (i) slow gait speed; (ii) muscle weakness; (iii) low physical activity; (iv) exhaustion; and (v) unintentional weight loss. Results After multivariate adjustment, participants with the lowest kidney function were at higher risk of frailty (OR 1.57, 95% CI 1.02–3.50) than those with normal kidney function. In addition, after adjustment for multiple confounders, estimated glomerular filtration rate <30 was associated with a greater risk of the individual frailty components of weight loss (OR 2.14, 95% CI 1.11–4.12), low physical activity (OR 1.35, 95% CI, 1.01–2.54) and slowness (OR 1.82, 95% CI 1.36–3.77) compared with estimated glomerular filtration rate ≥60. Conclusions Lower kidney function was associated with a higher risk of weight loss, low physical activity and slowness among community‐dwelling Japanese older adults.

The paper examines the value‐generating strategies used in some of New Zealand's primary activities in a rapidly changing trading context in which the countries of East Asia increasingly figure. These strategies range from scaling up volume, with a consequent conspicuous impact on rural landscapes, to innovative value‐enhancing relationships linking producers, processors and consumers in processes which value landscapes for the contribution they make to provenance stories. Our argument is that higher‐value strategies are necessarily more intensely collaborative and involve a pursuit of engaged relationships, especially between onshore producers and manufacturers and consumers at a distance. We term this collaborative form of strategising as ‘the relationships economy’. We illustrate our argument using two case studies, dairying and merino. While there are great differences in scale between them, and dairying focuses significantly on volume‐generating capacity, there are players in dairying who are adopting higher‐value relationships‐based approaches similar to those developed in the merino industry. The common thread connecting the case studies is that of intentional enactment, which echoes earlier periods in New Zealand's trading history when considerable work was undertaken by industry participants to create new markets for primary products.

The 2010 Affordable Care Act extended dependent coverage for adult children up to age 26 in the USA. Since then, considerable studies have assessed its various impacts among young adults. However, little is known about whether there is any change in health care use when young adults age out of dependent coverage. This study examines health care consumption changes among young adults prior to their aging out process. I used data from a large insurance claim database and studied health care utilization of young adults under parents' coverage during a 2‐year period in a difference‐in‐difference framework. I found that young adults had relative reductions in health services use, except ER visits, compared with individuals who stayed under parents' coverage. This pattern was the same for both male and females. Individuals with regular medical needs had greater relative reductions compared with those without regular medical needs. The relative reductions in health care use during the aging out process may have an important impact on young adults' health, especially for those with regular medical needs. More efforts could be made to help them maintain regular medical utilization during the transition.

Objective We examine whether drugs’ excluded versus recommended status on pharmacy benefit manager exclusion lists corresponds to evidence from cost‐effectiveness analyses, lack of evidence, or rebates. Data Sources To find cost‐effectiveness data for drugs on 2016 exclusion lists of CVS Caremark and Express Scripts, we searched the Tufts Cost‐Effectiveness Analysis Registry and the peer‐reviewed literature. Study Design For each excluded and recommended drug, we compared the mean cost‐per‐QALY, and we calculated the difference between the numbers of excluded and recommended drugs for which we could find no cost‐effectiveness evidence. Data Collection As keywords in our searches, we used the brand and generic drug name and “cost‐effectiveness” and “cost‐per‐quality‐adjusted life‐year.” Of 240 retrieved studies, 110 were selected for analysis. Principal Findings The mean cost‐per‐QALY for excluded drugs was higher ($51,611) than the cost‐per‐QALY for recommended drugs ($49,474), but not statistically significant. We could find no cost‐effectiveness evidence in the Registry or peer‐reviewed literature for 23 of the excluded drugs, and no evidence for 5 of the recommended drugs. Conclusions Cost‐effectiveness does not correlate with a drug's excluded or recommended status. Lack of cost‐effectiveness evidence favors a drug's excluded status.

Objective To build and test a model that predicts community discharge probabilities for Medicaid‐eligible nursing home (NH) residents who remain in the nursing home at 90 days after admission and, thus, would be candidates for the Money Follows the Person (MFP) program. Data Source The Minimum Data Set, Medicaid Management Information Systems, and Minnesota Vital Statistics file. Data Cohort of 33, 590 nursing home stays that qualified for Medicaid by the 90th day of their stay from 383 Minnesota nursing homes from July 2011 to June 2013. Study Design Mixed effects logistic regression model to predict community discharge. Principal Findings The scoring system had a high level of accuracy in predicting community discharge for both the fitting and validation cohorts. Subpopulations with severe mental illness or intellectual disability were well represented across the entire score range. Conclusions Findings are being applied in the Minnesota's MFP initiative (Moving Home Minnesota) to target Medicaid‐eligible NH residents for transitioning to the community. This approach could be applied to MFP in other states.

Objective To examine the effects of the penetration of dual‐eligible special needs plans (D‐SNPs) on health care spending. Data Sources/Study Setting Secondary state‐level panel data from Medicare‐Medicaid Linked Enrollee Analytic Data Source (MMLEADS) public use file and Special Needs Plan Comprehensive Reports, Area Health Resource Files, and Medicaid Managed Care Enrollment Report between 2007 and 2011. Study Design A difference‐in‐difference strategy that adjusts for dual‐eligibles’ demographic and socioeconomic characteristics, state health resources, beneficiaries’ health risk factors, Medicare/Medicaid enrollment, and state‐ and year‐fixed effects. Data Collection/Extraction Methods Data from MMLEADS were summarized from Centers for Medicare and Medicaid Services (CMS)'s Chronic Conditions Data Warehouse, which contains 100 percent of Medicare enrollment data, claims for beneficiaries who are enrolled in the fee‐for‐service (FFS) program, and Medicaid Analytic Extract files. The MMLEADS public use file also includes payment information for managed care. Data in Special Needs Plan Comprehensive Reports were from CMS's Health Plan Management System. Principal Findings Results indicate that D‐SNPs penetration was associated with reduced Medicare spending per dual‐eligible beneficiary. Specifically, a 1 percent increase in D‐SNPs penetration was associated with 0.2 percent reduction in Medicare spending per beneficiary. We found no association between D‐SNPs penetration and Medicaid or total spending. Conclusion Involving Medicaid services in D‐SNPs may be crucial to improve coordination between Medicare and Medicaid programs and control Medicaid spending among dual‐eligible beneficiaries. Starting from 2013, D‐SNPs were mandated to have contracts with state Medicaid agencies. This change may introduce new effects of D‐SNPs on health care spending. More research is needed to examine the impact of D‐SNPs on dual‐eligible spending.

Objective To examine associations among substance use disorder (SUD) and measures of length of stay (LOS) and non‐psychiatric medical comorbidity (MEDCO) in older‐adult inpatients with serious mental illness (SMI), hypothesizing SUD would be related to worse clinical outcomes. Methods A cross‐sectional study analyzed medical records from 2010 to 2016 of 7258 inpatients with SMI ≥ age 50, obtained from a 274‐bed psychiatric hospital. Descriptive analyses examined prevalence rates for SUD status (+/−), individual drug classes, and total number of SUDs (polysubstance use disorders). Regression models examined the influence of 2 independent variables of interest: (1) SUD status (+/−) and (2) type of SUD (ie, specific drug), controlling for demographic factors and additional (non‐SUD) psychiatric disorders. Two dependent (outcome) variables were examined: LOS and MEDCO. Results The overall SUD rate was 26%; cocaine was the most common SUD (≈ 10%). SUD status and additional (non‐SUD) psychiatric diagnoses were significantly associated with longer LOS (both P < 0.001). For individual SUDs, cocaine, marijuana, opiates, and alcohol were all significantly associated with LOS (all P < 0.01). SUD status, age, sex, admission status, and race were significantly associated with MEDCO (all P < 0.002). For individual SUDs, barbiturates, opiates, and alcohol were all significantly associated with MEDCO (P < 0.01). Conclusions The prevalence of SUD in this sample underscores concerns related to treating older adults presenting providers with comorbid SUD and SMI. This combination may increase the burden and complexity of care, warranting further investigation into mechanisms and long‐term consequences.

Aim The aim of the present study was to evaluate whether the effect of one‐time brief additional counseling in periodic health examinations (PHE) through the National Screening Program for the Translational Ages in Korea is sustained after 2 years. Methods We collected data from National Screening Program for the Translational Ages participants in 2007 and 2008. To evaluate behavior change after 2 years, we collected the participants’ health behavior data 2 years later (2009 and 2010). We defined the basic group as participants who only received PHE, and the additional group as received PHE and counseling. We carried out propensity score matching to ensure that additional counseling was the only different variable affecting health behavior between the two groups. Results After propensity score matching, 50 630 remaining matched participants were matched for each group. Of these participants, 26.5% (26 855/101 260) were aged 66 years, and 60.9% (61 653/101 260) were men. The additional group showed a significant increase in odds of smoking cessation among the 66‐year‐olds (adjusted OR 1.173, 95% CI 1.003–1.372). This effect was significant, especially when the participants did not have hypertension or hypercholesterolemia (adjusted OR 1.193, 95% CI 1.000–1.423 for hypertension and adjusted OR 1.188, 95% CI 1.009–1.398 for hypercholesterolemia). However, there was no significant association for alcohol drinking and regular exercise. Conclusions The effect of one‐time brief counseling added to a PHE in cigarette smoking was observed only among the 66‐year‐olds. However, the effect was so small that it is doubtful to be clinically relevant. Repeated counseling is required to sustain the effect of the initial motivation of counseling. Geriatr Gerontol Int 2017; ••: ••–••

This paper presents a copula‐based method for identifying and estimating the coefficient of a binary endogenous regressor in a Poisson regression. The method offers advantages over existing approaches. Most importantly, it relies upon standard maximum likelihood approaches, and it does not require numerical integration. Further, as part of its implementation, the method provides a convenient test for the presence of endogeneity. The empirical application investigates the effect of insurance status (a binary measure) on doctor visits (a count measure).

Literature examining WTO+ commitments in services trade agreements (STAs) has not considered the role of services regulation. We bridge this gap using a sample of 15 South/South‐East Asian countries, given the burgeoning trend of Asian economies towards services preferentialism and the largely WTO+ nature of their preferential services commitments. Our empirical findings suggest that Asian trading dyads with regulatory frameworks that are more similar and more trade restrictive tend to undertake higher levels of WTO+ commitments in their STAs. There is also evidence in our results, including by modes of supply, for WTO+ commitments in Asian STAs being driven by goods trade complementarities, alluding to supply chain dynamics in the region. Such results support the hypothesis that the heightened “servicification” of production generates a demand to lower services input costs arising from regulatory incidence and heterogeneity.

Objective To investigate the impact on patient waiting times of a role substitution model introducing an advanced allied health practitioner as the first point of contact within a geriatric outpatient context. Methods A pre‐ to postintervention design was used to determine impact over a five‐year period (2008–2012). All patients referred to the geriatric specialist outpatient department were included (n = 1514). Data relating to waiting times were analysed using one‐way ANOVA and post hoc Tukey tests to determine effects on patient waiting times. Results Waiting times were reduced from an average of 82 to as low as 35 days, in a context of increasing referral rates. Medical specialist capacity was increased through improvements to available outpatient times and reduced appointment lengths. Patients seen within their designated triage category timeframe increased from 47 to 86%. Conclusion Health professional substitution in geriatrics can be an effective intervention for reducing patient waiting times and improving access to care.

In this paper, we show theoretically and empirically that the US quantitative easing (QE) policy results in lower exchange rate pass‐through into the destination prices of Chinese exporters. In addition, the more the exchange rate in the export destination appreciates than the Chinese yuan, the stronger this effect becomes. Our model combines various marginal effects of QE policy on the destinations of Chinese exporters and variable markups of export firms due to strategic complementarities. The model predicts that the impact of US QE policy on the pass‐through of Chinese exporters depends on its spillover on the exchange rate between China and the export destination of different firms. We provide strong support for the model predictions using Chinese firm‐product‐level data with information on export destinations. The baseline result and the heterogeneity we find in the response of exchange rate pass‐through of Chinese exporters to US QE policy remain robust to alternative measures of samples and controls.

This study investigates whether the European Union's funding of civil society organizations (CSOs) can foster equal access to existing channels of participation. This is analyzed by using data from 7,889 CSOs that are registered in the EU Transparency Register. Two criteria should be met for funding to combat inequalities among CSOs: the funding must support underrepresented interests, and it must increase their participation in the policy process. The results of a logistic regression analysis show that the Commission's funding scheme does support underrepresented interests but makes participation more unequal by also supporting already overrepresented groups. Furthermore, the analysis shows that the probability of a CSO having access to formal channels of participation significantly increases if it has received funding. The conclusion is that funding could be used more efficiently if the Commission were to consistently support underrepresented interests.

Despite its high political interest, the impact of removing user charges for health care in low‐income settings remains a debatable issue. We try to clear up this contentious issue by estimating the short‐term effects of a policy change that occurred in 2006 in Zambia, when 54 of 72 districts removed fees. We use a pooled synthetic control method in order to estimate the causal impact of the policy on health care use, the provider chosen, and out‐of‐pocket medical expenses. We find no evidence that user fee removal increased health care utilisation, even among the poorest group. However, we find that the policy is likely to have led to a substitution away from the private sector for those using care and that it virtually eliminated medical expenditures, thereby providing financial protection to service users. We estimate that the policy was equivalent to a transfer of US$3.2 per health visit for the 50% richest but of only US$1.1 for the 50% poorest.

Aim To investigate whether being part of a community organization interfered with older adults’ overall functionality. The magnitude of responses to a community exercise program based on functional circuits in socially active and socially non‐active older adults was also investigated. Methods A total of 200 older adults aged ≥60 years from Requinoa, Chile, participated in the study. Participants were separated into two groups according to the level of social participation: socially active (SA) and socially non‐active (SNA). During an evaluation, data regarding the presence of comorbidities (Charlson Comorbidity Index), disability level (Modified Health Assessment Questionnaire), dynamic balance (Timed Up and Go test), muscle force (handgrip dynamometry) and sociodemographic conditions were collected. Participants followed an exercise program consisting of a functional exercise circuit including balance, resistance and aerobic exercises, twice a week, for 12 weeks. Results Both the Charlson Comorbidity Index and disability were higher in SNA compared with SA participants on inclusion. Both groups improved disability (Δ–0.25 patients [−0.5 – −0.0625 patients] for SNA and (Δ–0.125 patients [−0.5–0 patients] for SA) and balance (Δ–2 s [−3–0 s] for SNA and (Δ–1 s [−3–0 s] for SA) after training (P < 0.05 for all). Changes from baseline were statistically higher in the SNA group. Handgrip force improved only in participants in the SNA group (Δ1.7 kg [0.6–2.8 kg], P = 0.0001). No differences, however, were observed between the magnitude of improvements of handgrip between groups. Conclusions Although socially non‐active older adults had more comorbidity and disability than their socially active counterparts, they showed a higher response to a community exercise program. Geriatr Gerontol Int 2017; ••: ••–••.

Using quarterly data from 1995 until 2014, we investigate whether Euro Area (EA) membership influences the probability of a European Union Member State going through an episode of sudden stop or through an episode of bonanza, after controlling for a number of push and pull factors. Overall, our results do not support the claim that EA membership constituted a weakness during the recent financial crisis. On the contrary, we find that EA membership decreases the probability of a sudden stop, all else equal. We find no evidence that being part of the EA has a direct effect on the probability of bonanza. When allowing for interaction effects, our results suggest that EA membership might have mitigated the risk perception arising from higher government debt in the case of bonanzas.

Purpose This study examined the time from breast cancer diagnosis to initiation of treatment among Alaska Native (AN) women. We evaluated the impact of age, cancer stage, and rural/urban residence at diagnosis. Methods We evaluated characteristics of women recorded in the Alaska Native Tumor Registry who received a first diagnosis of breast cancer between 2009 and 2013. Median time from diagnosis to treatment was assessed. Associations of demographic and clinical characteristics with timely initiation of treatment were evaluated using logistic regression and Cox proportional hazards models. Results Two hundred seventy‐eight (278) AN women were diagnosed with invasive breast cancer in years 2009‐2013. Mean age at diagnosis was 56.8 years (SD = 13.0). The median time from diagnosis to initiation of treatment was 23 days (P < .05) with most (94.6%, n = 263) meeting the ≤60‐day guideline target. Time to treatment was not associated with rural/urban residence, age, or stage at cancer diagnosis. Conclusion These findings indicate that most AN women diagnosed with breast cancer within the AN Tribal Health System receive timely treatment after diagnosis.

Background Malaria is a major global health challenge. This study aims to clarify the manner in which contextual factors determine the use and maintenance of bed nets and the extent to which malaria prevention policy is responsive to them in Southern Benin. Methods Semi‐structured interviews and direct observations were undertaken with 30 pregnant women in the municipality of So‐Ava from June to August 2015. Key informants in the Ministry of Health and local community health workers were also interviewed regarding malaria prevention policy formation, and the monitoring and evaluation of bed net interventions, respectively. Data were analyzed through categorical content analysis and grouped into themes. Results The majority of pregnant women participants (80%) declared non‐adherence to instructions for hanging and maintaining insecticide‐treated nets (ITNs). The distributed bed nets were washed like clothes, which affected their bio‐efficacy, and were in poor condition (ie, torn or had holes). Multiple factors contributed to the poor condition of ITNs: Pregnant women's limited understanding of risk including their inability to connect the key environmental factors to personal risk, gendered responsibility for installing bed nets, and lack of public measures that would enable women to re‐treat or access new bed nets as needed. Poverty that determined structural aspects of housing such as the size and quality of homes and access to bed nets exacerbated the challenges. Conclusion Institutionalizing an iterative process of monitoring, review, and responsive adaptation throughout the entire policymaking cycle would better support malaria preventive policy implementation in Benin.

This study investigates the sourcing patterns of Japanese export‐platform foreign affiliates in Mexico, which mainly export to the United States and Canada. We propose a novel approach to estimate intermediate input elasticities of exports by sourcing country. We find that, on average, Japanese export‐platform foreign affiliates in Mexico source intermediate inputs from third countries, including the United States and Canada, rather than from Japan and Mexico, suggesting that Japanese export‐platform foreign affiliates in Mexico are mainly integrated into the vertical production networks back and forth between Mexico, the United States and Canada. In turn, Japanese foreign affiliates selling domestically in Mexico source intermediate inputs not only within the North American Free Trade Agreement countries but also from Japan. In addition, we find that export‐platform foreign affiliates in Mexico use more labour‐intensive production than do foreign affiliates selling domestically in Mexico. This suggests that saving labour costs is one of the motives for export‐platform foreign direct investment in Mexico.

Introduction Administration is vital for health care. Its importance may increase as health care systems become more complex, but academic attention has remained minimal. We investigated trends in administrative expenditure across OECD countries, cross‐country spending differences, spending differences between health care system typologies, and differences in the scale and scope of administrative functions across typologies. Methods We used OECD data, which include health system governance and financing‐related administrative activities by regulators, governance bodies, and insurers (macrolevel), but exclude administrative expenditure by health care providers (mesolevel and microlevel). Results We find that governance and financing‐related administrative spending at the macrolevel has remained stable over the last decade at slightly over 3% of total health spending. Cross‐country differences range from 1.3% of health spending in Iceland to 8.3% in the United States. Voluntary private health insurance bears much higher administrative costs than compulsory schemes in all countries. Among compulsory schemes, multiple payers exhibit significantly higher administrative spending than single payers. Among single‐payer schemes, those where entitlements are based on residency have significantly lower administrative spending than those with single social health insurance, albeit with a small difference. Discussion These differences can partially be explained because multi‐payer and voluntary private health insurance schemes require additional administrative functions and enjoy less economies of scale. Studies in hospitals and primary care indicate similar differences in administrative costs across health system typologies at the mesolevel and microlevel of health care delivery, which warrants more research on total administrative costs at all the levels of health systems.

Background Few studies explore stroke survivor views and motivations towards stem cell therapy (SCT). This qualitative study explores the views and motivations of both stroke survivors and their partners/carers towards a proposed 2‐arm Phase III Randomised Controlled Trial (RCT) comparing intracerebral insertion of stem cells with placebo neurosurgery in stroke survivors with disability. Objective To explore views and motivations towards a proposed 2‐arm stem cell trial and identify factors that may impede and enhance participation. Design This study adopts a naturalistic design to explore the complexity of this field, employing a participatory action‐research approach comprising a specialized Conversation (World) Café form of focus group. Data were collected via 5 Conversation Cafés with stroke survivors (age 40‐75) and partners/carers between June and October 2016. Of 66 participants, 53 (31 male, 22 female) were stroke survivors and 13 (6 female, 7 male) were partners/carers. Qualitative data were analysed using a thematic approach. Discussion and Conclusion Stroke survivor views and motivations reflect anticipation of the personal and future benefits of regenerative medicine. Partners/carers sought to balance the value of stroke survivor hope with carrying the weight of hope as carer, a conflict burden adding to known caregiver burden. All participants expressed the need for during and post‐trial psychological support. This study provides a rare opportunity to explore the prospective views and motivations of stroke survivors and their partners/carers towards a proposed Phase III 2‐arm RCT. This adds weight to qualitative evidence exploring capacity, consent, decision making, perceptions of treatment risk and supports required for clinical trial participation.

Introduction Neuropsychiatric symptoms (NPS) are common at all stages of Alzheimer disease (AD). Delusions in AD are associated with negative clinical consequences and may signal rapid disease progression. Hence, we sought to determine the prevalence of delusions in drug‐naïve (no cholinesterase inhibitor or neuroleptic medications) AD patients. Methods In this meta‐analysis, a search of the EMBASE, MEDLINE, and PsycINFO databases was performed. We selected studies reporting delusion prevalence measured by the Neuropsychiatric Inventory (NPI) in drug‐naïve AD patients. An aggregate delusion event rate with 95% confidence interval (CI) was calculated. The I2 statistic was used to assess the magnitude of between‐study heterogeneity. Single variable meta‐regressions allowed examination of the effect of moderating factors and heterogeneity. Quantitative measures were used to appraise for publication bias. Results We identified 6 studies with 591 participants allowing calculation of the aggregate delusional prevalence rate. Irrespective of dementia severity, the aggregate event rate for delusions was 29.1% (95% CI: 20–41%; I2 = 84.59). No publication bias was observed. Conclusion This meta‐analysis calculates a 29.1% prevalence rate of delusions in AD patients. There is a trend towards increasing delusion prevalence in concordance with increasing severity of dementia. Given delusions are associated with poorer outcomes, the obtained prevalence should motivate clinicians to screen carefully for delusions. Current literature limitations warrant future studies, with sub‐analyses on dementia severity, and other neurobiological factors known to influence the presence of delusions.

Purpose To examine the relationship between area population density and community pharmacy‐based Alzheimer's Disease (AD)‐related services: pharmacists’ medication knowledge and counseling, immunizations, and in‐stock cognitive enhancers in 3 predominantly rural regions of the United States. Methods A standardized interview was administered by telephone to a 100% sample of community pharmacies in 3 areas: Northern California/Southern Oregon (n = 206), North and South Dakota (n = 278), and West Virginia (n = 420). Key study outcomes included: pharmacists’ medication knowledge, availability of immunization services, and cognitive enhancers in stock. Respondents were classified by population density (persons/mi2) by pharmacy location to evaluate the relationship between rurality and AD‐related pharmacy services. Chi‐squared and logistic regression analyses were performed using Stata 10.1. Findings Pharmacies in more rural areas (50.1‐100.0, 25.1‐50.0, and ≤25.0 persons/mi2) were about 50% less likely to offer immunizations (95% CI: 0.32‐0.91; 0.32‐0.76; 0.28‐0.80, respectively) compared to the least rural areas (>100.0 persons/mi2). Compared to the least rural areas, pharmacists in the most rural areas (≤25.0 persons/mi2) were less likely to name ≥2 gastrointestinal adverse effects of donepezil (OR = 0.50, 95% CI: 0.31‐0.82) or have memantine XR 28 mg (OR = 0.61, 95% CI: 0.41‐0.89) and other surveyed medications (OR = 0.57, 95% CI: 0.39‐0.82) in stock. Conclusions We found disparities in AD‐related services in community pharmacies located in more rural counties, wherein individuals with AD and their caregivers may face barriers to obtaining quality pharmaceutical care. There is a need to strengthen pharmacists’ knowledge and improve pharmacy services to reduce disparities.

A growing literature highlights complexity of policy implementation and governance in global health and argues that the processes and outcomes of policies could be improved by explicitly taking this complexity into account. Yet there is a paucity of studies exploring how this can be achieved in everyday practice. This study documents the strategies, tactics, and challenges of boundary‐spanning actors working in 4 Sub‐Saharan Africa countries who supported the implementation of multisectoral nutrition as part of the African Nutrition Security Partnership in Burkina Faso, Mali, Ethiopia, and Uganda. Three action researchers were posted to these countries during the final 2 years of the project to help the government and its partners implement multisectoral nutrition and document the lessons. Prospective data were collected through participant observation, end‐line semistructured interviews, and document analysis. All 4 countries made significant progress despite a wide range of challenges at the individual, organizational, and system levels. The boundary‐spanning actors and their collaborators deployed a wide range of strategies but faced significant challenges in playing these unconventional roles. The study concludes that, under the right conditions, intentional boundary spanning can be a feasible and acceptable practice within a multisectoral, complex adaptive system in low‐ and middle‐income countries.

A trend of the shortening duration of pregnancies carried to term has been observed in several countries and represents a growing public health concern. This paper describes the trend in the Czech Republic and shows its relation to the changing demographic structure of mothers and the organisation of maternity care. Data from the birth register are used and supplemented with information about the capacity of maternity care (number of beds at maternity clinics, number of obstetricians and midwives). Logistic regression is used to estimate the odds of 37 to 39 vs 40+ completed weeks of gestation. The results show that the average gestational age at term decreased by 2.1 days between 2000 and 2013. The odds of 37 to 39 weeks of gestational duration increased, mainly due to the reduction in the number of beds at maternity clinics (adjusted odds ratio of 1.51). The effects of the number of health care staff members were weaker. The number of midwives positively influenced gestational duration, while the number of obstetricians had a negative effect. Maternal demographic structure cannot explain the trend. A likely explanation is the increased use of planned early term caesarean sections.

Background Social network processes impact on the genesis and management of mental health problems. There is currently less understanding of the way people negotiate networked relationships in times of crisis compared to how they manage at other times. Objective This paper explores the patterns and nature of personal network involvement at times of crises and how these may differ from day‐to‐day networks of recovery and maintenance. Method Semi‐structured interviews with 25 participants with a diagnosis of long‐term mental health (MH) problems drawn from recovery settings in the south of England. Interviews centred on personal network mapping of members and resources providing support. The mapping interviews explored the work of network members and changes in times of crisis. Interviews were recorded, transcribed and analysed using a framework analysis. Results Three key themes were identified: the fluidity of network relationality between crisis and recovery; isolation as a means of crises management; leaning towards peer support. Personal network input retreated at times of crisis often as result of “ejection” from the network by participants who used self‐isolation as a personal management strategy in an attempt to deal with crises. Peer support is considered useful during a crisis, whilst the role of services was viewed with some ambiguity. Conclusions Social networks membership, and type and depth of involvement, is subject to change between times of crisis and everyday support. This has implications for managing mental health in terms of engaging with network support differently in times of crises versus recovery and everyday living.

Objective Despite the benefits of physical activity (PA) in older people with depression, many do not comply with the International PA guidelines. Thus, we investigated what factors influence PA participation among 915 community‐dwelling older adults (aged ≥65 years) with depression in 6 low‐income and middle‐income countries (LMICs). Methods Cross‐sectional data were analyzed from the World Health Organization's Study on Global Ageing and Adult Health. The sample was restricted to those with DSM‐IV depression or receiving depression treatment in the last 12 months. PA was assessed by the Global Physical Activity Questionnaire. Participants were dichotomized into low (ie, not meeting 150 minutes of moderate PA per week) and moderate‐to‐high physically active groups. Associations between PA and a range of correlates were examined using multivariable logistic regressions. Results The prevalence of low PA was 40.4% (95%CI = 34.8%–46.1%). After adjusting for age, sex, and country, larger household size and unemployment were significant sociodemographic correlates of low PA. Former smoking (vs never), anxiety, mild cognitive impairment (MCI), lower body mass index, bodily pain, asthma, chronic back pain, chronic obstructive pulmonary disease, hearing problems, stroke, slow gait, poor self‐rated health, higher levels of disability, and lower levels of social cohesion were identified as significant negative correlates of PA. Conclusions The current data provide guidance for future interventions across LMICs to assist older people with depression engage in regular PA. The promotion of social cohesion may increase the efficacy of future public health initiatives, while from a clinical perspective, somatic co‐morbidities, MCI, pain, and slow gait need to be considered. Key points More than 40% of older people with depression in low‐income and middle‐income countries do not meet physical activity guidelines. Somatic co‐morbidities, lower body mass index, pain, and slow gait need to be considered. The promotion of social cohesion may increase the efficacy of future public health initiatives.

Objective To determine how older people with dementia and their family caregivers experience dementia assessment services and preferences for future configuration of diagnostic services. Methods Qualitative, semistructured in‐depth interviews were conducted with nine individuals with dementia. In seven instances, the caregiver also took part in the interview, and on two occasions, the interview was with the person with dementia only. Results An important contact during assessment of dementia was the general practitioner, in particular working in a way or timeframe which provides clarity and comfort to the person with dementia and their family members. A problematic factor in clear diagnosis was when probable dementia was suspected during hospitalisation for another complaint. Participants expressed a wide range of views in terms of preferred settings for diagnostic services. Conclusion These findings highlight some key considerations, which should be included in future research leading to decisions about the design of dementia client services.

This article starts with discussing principles for a globally just system of refugee protection to which states contribute either by admitting refugees for resettlement or by supporting refugee integration in other states. Such a system requires relatively strong assurances of compliance by the states involved, which are absent in the international arena. In the European Union, however, the Member States form a predetermined set with prior commitments and supranational institutions that facilitate effective burden sharing. The article traces the failure of the EU's relocation scheme to meet this expectation to misconceptions how to determine fair shares, to incomplete prior harmonization of normative standards, and to contradictions between the Dublin Regulation's principle of assigning responsibility to first countries of entry, on the one hand, and the Schengen principle of open internal borders, on the other hand.

This article analyzes how Member States have used the opportunities and avoided the constraints of the EU's multilevel governance architecture to return unwanted migrants. Drawing on sociological approaches to the EU and a broad understanding of return policies, we investigate the ways in which the northern Member States, notably Germany and Austria, have increasingly relied upon the EU's operational and financial resources to achieve their goal of pursuing a bold return policy. A key ‘usage’ of Europe has been the pooling of political and financial power to externalize and informalize its return policy. At the same time, the northern Member States' deliberate – yet widely under‐researched – ‘non‐use’ of Europe, such as using and maximizing national leeway, has been an equally important strategy to reduce migratory pressure and achieve higher return rates.

The Trans‐Pacific Partnership (TPP) trade agreement, if were it to be successfully implemented, would be one of the largest regional agreements ever seen. It is the only exemplar to date of a “mega‐regional” FTA for which negotiations have been successfully concluded, and a landmark in evolving approaches to Asia–Pacific integration. As such, quantitative assessments of its potential effects are of considerable interest. One of the most widely used techniques for evaluating the economic impact of regional trading agreements is numerical simulation with computable general equilibrium, or CGE, models. There have now been a large number of papers written that use CGE methods to analyse the potential economic impact of the TPP agreement under varying theoretical and policy assumptions. In this paper we provide a synthesis of the key results that have emerged from the literature, and introduce some new simulation results of our own to anchor the discussion.

In April 2005, Lucio Gutiérrez was removed from office in the context of a fast‐growing economy. With no economic hardship to fuel social outrage, the failure of Gutiérrez illustrates how political and institutional factors can be the most important forces determining presidential survival. In this article, we qualitatively analyse the path toward confrontation between Gutiérrez and the congressional opposition which led to his political demise. We find that Ecuador's weak democratic tradition working through more proximate causes – radicalism, normative preference for democratic institutions and a negative institutional equilibrium – coupled with other institutional and political variables accelerated Lucio Gutiérrez's fall from power.

Objectives To investigate the association between hospital safety culture and 30‐day risk‐adjusted mortality for Medicare patients with acute myocardial infarction (AMI) in a large, diverse hospital cohort. Subjects The final analytic cohort consisted of 19,357 Medicare AMI discharges (MedPAR data) linked to 257 AHRQ Hospital Survey on Patient Safety Culture surveys from 171 hospitals between 2008 and 2013. Study Design Observational, cross‐sectional study using hierarchical logistic models to estimate the association between hospital safety scores and 30‐day risk‐adjusted patient mortality. Odds ratios of 30‐day, all‐cause mortality, adjusting for patient covariates, hospital characteristics (size and teaching status), and several different types of safety culture scores (composite, average, and overall) were determined. Principal Findings No significant association was found between any measure of hospital safety culture and adjusted AMI mortality. Conclusions In a large cross‐sectional study from a diverse hospital cohort, AHRQ safety culture scores were not associated with AMI mortality. Our study adds to a growing body of investigations that have failed to conclusively demonstrate a safety culture–outcome association in health care, at least with widely used national survey instruments.

This article examines the role of non‐financial interest groups in EU financial regulatory decision‐making. While regulatory capture theories clearly helped identify the causes for the incrementality in spite of the major shock the 2008 crisis had caused, this article will consider a range of regulatory policy initiatives that do not neatly conform with this theory. I examine the extent to which non‐financial groups are able to have their preferences met in the making of three different consumer policies: the Mortgage Credit Directive (MCD), stricter regulations of retail investment products (PRIPs/KID) and the reform of EU level supervisory structures. By employing a process‐tracing approach based on qualitative interviews to analyze political responses to the 2008 financial crisis, the article demonstrates that newly mobilized groups could translate key advocacy goals into policy by deploying counter‐expertise and co‐operating with policy‐makers in some cases but not in others.

Due to its fast economic growth and lifestyle changes, China is experiencing a rapid epidemiological transition from communicable to noncommunicable diseases (NCDs). Mental disorder such as depression is an important yet often neglected NCD and is becoming a growing cause of disability, suicides, and disease burden. This paper provides the first nationally representative estimate of the medical cost attributable to depression and depressive symptoms among the adult population in China. On the basis of the 2012 China Family Panel Studies survey, our results indicate that these mental health conditions have significant impacts on the individual medical expenditure, and they jointly contribute to 14.7% of total personal expected medical spending in China, with depression and depressive symptoms accounting for 6.9% and 7.8%, respectively. Given that patients with mental illness face multiple psychological and institutional barriers in seeking appropriate treatment, the high depression‐induced medical costs may be primarily driven by the cost‐shifting effect from mental health care to general health care, as mental disorders often coexist with other NCDs such as diabetes and hypertension. As an implication, our study calls for an urgent reform of China's mental health and insurance systems to remove the policy‐induced obstacles for the access to mental health care resources.

Aims The aim of the study is to verify the knowledge and practices of health professionals working in prenatal care (PNC) related with syphilis during pregnancy and to identify the main barriers to the implementation of protocols for the control of this disease. Methods A cross‐sectional study in Teresina, Brazil, from January to May 2015, was conducted with 366 physicians and nurses working in PNC, corresponding to 70% of eligible professionals. We evaluated 20 knowledge and practice criteria related to the diagnosis and treatment of syphilis during pregnancy with a 95% compliance standard. We performed descriptive analysis of the data and used χ2 statistical test to verify differences according to professional category. Results Only 2 criteria, “knowledge about mother to child transmission according to gestational age” and “counselling on infection,” reached 95% compliance. Knowledge of the epidemiological profile of congenital syphilis and the goal of elimination of congenital syphilis and knowledge about serological tests had scores below 50%, while practices related with posttest counselling, cure control, and treatment of partners reached 60%. We identified organisational barriers related to the late initiation of PNC, to the delayed return of syphilis test results, to the application of benzathine penicillin in primary care units and to the treatment of partners. Conclusions Strategies for early initiation of PNC, implementation of rapid tests for syphilis, ensuring treatment of pregnant women with penicillin, adequate partner treatment, and continued education of health professionals on clinical management and counselling in sexually transmitted diseases are necessary to eliminate congenital syphilis.

Background Patient engagement in research (PEIR) is promoted to improve the relevance and quality of health research, but has little conceptualization derived from empirical data. Objective To address this issue, we sought to develop an empirically based conceptual framework for meaningful PEIR founded on a patient perspective. Methods We conducted a qualitative secondary analysis of in‐depth interviews with 18 patient research partners from a research centre‐affiliated patient advisory board. Data analysis involved three phases: identifying the themes, developing a framework and confirming the framework. We coded and organized the data, and abstracted, illustrated, described and explored the emergent themes using thematic analysis. Directed content analysis was conducted to derive concepts from 18 publications related to PEIR to supplement, confirm or refute, and extend the emergent conceptual framework. The framework was reviewed by four patient research partners on our research team. Results Participants’ experiences of working with researchers were generally positive. Eight themes emerged: procedural requirements, convenience, contributions, support, team interaction, research environment, feel valued and benefits. These themes were interconnected and formed a conceptual framework to explain the phenomenon of meaningful PEIR from a patient perspective. This framework, the PEIR Framework, was endorsed by the patient research partners on our team. Conclusions The PEIR Framework provides guidance on aspects of PEIR to address for meaningful PEIR. It could be particularly useful when patient‐researcher partnerships are led by researchers with little experience of engaging patients in research.

First embodied by the European Supervisory Authorities in 2010, agency governance in the financial sector has gained momentum with the creation of the Single Resolution Board (SRB) – an EU agency with considerable competencies in banking prudential policy. Within a short period, backed by the ‘ESMA‐Short Selling case’ judgment, agencies have progressed from supporting the European Commission with their quasi‐rule making, to a more prominent role in the decision‐making process, potentially influencing policy‐makers' agenda. By engaging in a qualitative analysis of legal documents, official texts and relevant scholarship, this research note examines the formal framework and practical aspects of SRB's governance, in order to substantiate whether its establishment presents a ‘qualitative increase’ in financial sector agencification. At the same time, the research note highlights problematic issues arising because of the limitations set by the Meroni doctrine arguing that the Board's wide powers ‘on paper’ may prove challenging to implement in practice.

Does corruption influence trust in national institutions in the same way as trust in international institutions? Did this influence change over the economic crisis 2008? Using data from the European Social Survey, we examined the association between corruption and trust in national and European parliaments before and after the start of the Great Recession 2008. We found that over the Crisis, the effect of corruption on trust in national parliament became more negative than it was before 2008. We also discovered a positive association between corruption and trust in the EU before the Crisis. That is, states with a higher level of national corruption seem to have more trust in international institutions, such as the EU. However, this relationship disappears after 2008. Our findings contribute to the debates on the impact of corruption on trust in national and international institutions, and on the consequences of the Great Recession.

Whereas most research focuses on non‐compliant implementation, we lack understanding of implementers' incentives and abilities to outperform national legislation. This study investigates a largely under‐researched question: to what extent practical implementation exceeds levels of legislative compliance with EU requirements? To explain this phenomenon, we focus on the responsiveness of implementing actors to external (participation in transnational networks) and domestic pressures (national societal attitudes) for compliance with EU requirements and the availability of additional expertise at the implementation stage (bottom‐up). Moreover, implementing actors are unlikely to respond in the same way to different types of national legislative problems (top‐down). The findings suggest that implementers often outperform the transposition of EU laws. Practical outperformance depends on the level of societal support for external policies and is a response to incomplete or ambiguous domestic formal rules.

Sociologists of science emphasize the crucial role of the day‐to‐day practices of scholars in defining academic disciplines and epistemological schools. Taking the case of EU Studies (EUS), this article examines the key practice of normative writing. I analyze the degree to which 70 highly‐cited journal articles of political science writing in EUS explicitly or implicitly suggest that European integration or its institutions or policies are bad or good, flourishing or declining. I use this discourse analysis, plus biographical data on the authors of texts, to explain a major temporal pattern. Degrees of normativity in EUS articles progressively declined from the 1970s until the millennium, but then subsequently recovered. Factors ‘external’ to scholarship, such as the progressive intensification of European integration and crises faced by the EU help explain this pattern. However they interacted in complex ways with ‘internal’ academic factors, such as generational replacement, ‘mainstreaming’ and rivalries between sub‐disciplinary and theoretical camps.

The paper investigates the spatial interdependence of US MNE investments in the MENA region. Given the variations in resource endowments, governance structures and degree of infrastructure availability in MENA countries, one would expect these variables to affect an MNE's choice of FDI location. We do find that domestic non‐spatial factors such as own country inflation and governance measured by bureaucratic quality as well as infrastructure affect a host country's inward FDI. We also found that only one measure of natural resource endowment; that is, oil and gas exports were instrumental in attracting FDI. This non‐spatial result is generally robust and invariant to the two methodologies employed in this study, that is the spatially autoregressive (SAR) model and the spatial Durbin model (SDM). We found that neighbouring countries’ infrastructure availability measured either by “electricity used” or “energy used” affected FDI inflows in a host country. However, this spatial impact was found only in the SDM model. The spatial effects of neighbouring countries’ economic and political conditions and resource endowments were, however, not observed on a host country's inward FDI. The insignificance of both the surrounding market potential and the spatially weighted FDI suggests a purely horizontal motive of MNE investments in the MENA region.

This paper examines the relationship between China's exports, export tax rebates and exchange rate policy. It offers an explanation for why China's exports continued to rise under RMB real appreciations during the Asian financial crisis. Based on a traditional export demand model, we test our hypothesis that the counteracting effects of China's export tax rebate policy have diminished the effectiveness of real exchange rates in facilitating the resolution of trade imbalances under the current pegged exchange rate regime. We find evidence that RMB real appreciations during the crisis negatively affected China's exports, but the negative effects were mitigated by the positive effects of export tax rebates. We also find evidence of a long‐run relationship between China's exports and the other explanatory variables. The empirical evidence suggests that under the pegged exchange rate regime with limited adjustments, real exchange rate movements alone cannot resolve China's external imbalances. The policy implication of this study is that China needs to redirect its decades‐long export‐oriented development strategy to one that emphasises domestic demand‐oriented development and to replace the current pegged exchange rate regime with a market‐oriented more flexible exchange rate regime.

Little is known about the response of physicians to changes in compensation: Do increases in compensation increase or decrease labour supply? In this paper, we estimate wage elasticities for physicians. We apply both a structural discrete choice approach and a reduced‐form approach to examine how these different approaches affect wage elasticities at the intensive margin. Using uniquely rich data collected from a large sample of general practitioners (GPs) and specialists in Australia, we estimate 3 alternative utility specifications (quadratic, translog, and box‐cox utility functions) in the structural approach, as well as a reduced‐form specification, separately for men and women. Australian data is particularly suited for this analysis due to a lack of regulation of physicians' fees leading to variation in earnings. All models predict small negative wage elasticities for male and female GPs and specialists passing several sensitivity checks. For this high‐income and long‐working‐hours population, the translog and box‐cox utility functions outperform the quadratic utility function. Simulating the effects of 5% and 10% wage increases at the intensive margin slightly reduces the full‐time equivalent supply of male GPs, and to a lesser extent of male specialists and female GPs.

Evidence about cost‐effectiveness is increasingly being used to inform decisions about the funding of new technologies that are usually implemented as guidelines from centralized decision‐making bodies. However, there is also an increasing recognition for the role of patients in determining their preferred treatment option. This paper presents a method to estimate the value of implementing a choice‐based decision process using the cost‐effectiveness analysis toolbox. This value is estimated for 3 alternative scenarios. First, it compares centralized decisions, based on population average cost‐effectiveness, against a decision process based on patient choice. Second, it compares centralized decision based on patients' subgroups versus an individual choice‐based decision process. Third, it compares a centralized process based on average cost‐effectiveness against a choice‐based process where patients choose according to a different measure of outcome to that used by the centralized decision maker. The methods are applied to a case study for the management of acute coronary syndrome. It is concluded that implementing a choice‐based process of treatment allocation may be an option in collectively funded health systems. However, its value will depend on the specific health problem and the social values considered relevant to the health system.